Small pulmonary nodule localization techniques in the era of lung cancer screening: a narrative review

Abstract

The widespread adoption of high-resolution computed tomography (CT) screening has led to increased detection of small pulmonary nodules, necessitating accurate localization techniques for surgical resection. This review examines the evolution, efficacy, and safety of various localization methods for small pulmonary nodules. Studies focusing on localization techniques for pulmonary nodules ≤30 mm in diameter were included, with emphasis on technical success rates and complication profiles. Preoperative CT-guided techniques, including hook-wire (success rate 94-98%) and anchored needle localization (success rate >99%, dislodgement rate 0%) demonstrate high technical success rates, though with varying complication profiles. Microcoil localization (97-98% success) shows comparable efficacy with lower complication rates. Dye-based methods offer simplicity but can be limited by rapid diffusion. Newer techniques like medical adhesive localization (success rate up to 100%) and electromagnetic navigation bronchoscopy (97.2% success) show promise in reducing complications and improving accuracy. Intraoperative methods such as ultrasound and hybrid operating room approaches provide real-time guidance but may be limited by nodule characteristics and available expertise. This review presents a radar chart analysis comparing techniques across key parameters and introduces an innovative decision-making algorithm that considers nodule characteristics, patient factors, and institutional resources, providing practical guidance and serving as a reference for clinicians. While no single method is universally superior, the trend towards minimally invasive, precise, and flexible approaches is evident. Future research should focus on large-scale comparative studies and the integration of artificial intelligence for optimized technique selection and improved patient outcomes.

Introduction

The widespread adoption of high-resolution computed tomography (CT) screening has led to a significant increase in the detection of small pulmonary nodules, particularly in high-risk populations^[1]. This trend has been further amplified by the implementation of lung cancer screening programs and improvements in imaging technology. Small pulmonary nodules are typically defined as well-circumscribed, radiographic opacities measuring up to 30 mm in diameter, completely surrounded by aerated lung tissue^[2].

The management of these nodules presents a considerable clinical challenge. While many are benign, a proportion represent early-stage lung cancer or metastases from extrathoracic malignancies. The probability of malignancy varies with nodule size, density, and other radiographic features. For instance, solid nodules measuring 5-10 mm have a malignancy risk of 6-28%, while those exceeding 20 mm carry a 64-82% risk^[3]. Ground-glass opacities (GGOs) and part-solid nodules present additional diagnostic complexities due to their association with early adenocarcinomas^[4].

Video-assisted thoracoscopic surgery (VATS) has emerged as the preferred minimally invasive approach for both diagnosis and treatment of suspicious pulmonary nodules. VATS offers significant advantages over open thoracotomy, including reduced postoperative pain, shorter hospital stays, and fewer complications^[5]. However, VATS has limitations in localizing small, deep, or ground-glass nodules, which can be challenging to visualize or palpate during the procedure^[6].

Intraoperative localization of small pulmonary nodules, particularly those less than 10 mm in diameter or located more than 5 mm from the pleural surface, can be challenging^[7]. This difficulty is compounded for ground-glass opacities, which may be impossible to palpate even during open surgery. Failed localization can lead to prolonged operative times, increased risk of conversion to thoracotomy, or incomplete resection^[8].

To address these challenges, a variety of preoperative and intraoperative localization techniques have been developed. These methods aim to provide precise targeting of small nodules while minimizing invasiveness and complications. Preoperative CT-guided techniques, including hook-wire placement, microcoil insertion, and dye marking, have been widely adopted^[9-11]. Recent advancements have introduced novel localization techniques, such as robotic-assisted CT-guided localization^[12], cone-beam CT-guided marking in hybrid operating rooms^[13], and the use of indocyanine green (ICG) with lipiodol for bronchoscopic navigation^[14]. These emerging methods aim to improve accuracy and reduce complications associated with traditional techniques.

The ideal localization technique should offer high accuracy, low complication rates, minimal patient discomfort, and flexibility in terms of the interval between localization and surgery. Moreover, the technique should be adaptable to various nodule characteristics, such as size, depth, and density, and should not interfere with subsequent pathological examination^[15]. Additionally, cost-effectiveness and broad applicability across different healthcare settings are important considerations.

This integrated review aims to summarize and critically evaluate the various localization techniques currently available for small pulmonary nodules. We will examine the efficacy, safety profiles, and clinical applicability of each method, drawing from a synthesis of recent literature and clinical studies. Furthermore, we will explore the potential of combining multiple techniques and the role of advanced imaging technologies in improving localization outcomes. Comparative studies of different localization techniques are crucial in determining the most effective and safe methods for various clinical scenarios^[6]. By providing an up-to-date overview of these techniques, we hope to inform clinical decision-making and highlight areas for future research and development in this rapidly evolving field.

Methods

This narrative review was conducted to provide an integrated overview of localization techniques for small pulmonary nodules. We followed a structured approach to identify, analyze, and synthesize relevant literature on this topic.

Ethical Considerations: This narrative review did not involve direct human or animal subjects. Nevertheless, the study protocol was submitted to the Institutional Review Board, and an exemption was obtained. The authors conducted this review in accordance with ethical standards for scientific research, ensuring accurate representation of the literature and proper citation of all sources.

Literature Search: We performed a thorough search of electronic databases including PubMed, Embase, and the Cochrane Library. The search strategy employed combinations of relevant keywords and Medical Subject Headings (MeSH) terms, including but not limited to: “pulmonary nodule,” “lung nodule,” “localization,” “hookwire,” “microcoil,” “dye marking,” “electromagnetic navigation bronchoscopy,” and “video-assisted thoracoscopic surgery.” Additional terms such as “robotic-assisted localization,” “cone-beam CT,” and “hybrid operating room” were included to capture recent technological advancements^[12,13]. The primary search was focused on English-language articles published between January 2008 and August 2024 to ensure currency of information. However, some seminal earlier works were also included to provide historical context and an integrated overview of developments in the field.

Inclusion Criteria: We included original research articles, systematic reviews, meta-analyses, and notable case series that focused on localization techniques for pulmonary nodules ≤30 mm in diameter. Studies addressing both solid and subsolid nodules were considered. We particularly sought articles that provided data on technical success rates, complication profiles. Comparative studies evaluating multiple localization techniques were given special attention^[6,15].

Exclusion Criteria: Studies focusing exclusively on large pulmonary masses (>30 mm) or those primarily addressing diagnostic techniques without localization were excluded. Conference abstracts and non-peer-reviewed publications were also omitted.

Data Extraction and Synthesis: Two reviewers independently screened titles and abstracts for relevance. Full-text articles of potentially eligible studies were then assessed. Data extraction was performed using a standardized form to capture key information including study design, sample size, nodule characteristics, localization technique details, success rates, complications, and limitations. We also extracted data on patient comfort, procedure duration, and the interval between localization and surgery when available^[14]. Given the narrative nature of this review, we did not perform a formal quality assessment of included studies. Instead, we critically appraised the methodology and findings of key studies during the synthesis process.

Data Synthesis: The extracted information was organized thematically, grouping localization techniques into preoperative, intraoperative, and combined approaches. Within each category, we synthesized data on technical aspects, efficacy, safety, and clinical applicability. Where available, we included quantitative data on success rates and complication incidences. However, given the heterogeneity of study designs and outcome measures, we did not perform meta-analyses.

We also sought to identify trends in technique development, emerging technologies, and areas of ongoing debate or uncertainty in the field. Special attention was given to novel approaches such as the “sandwich marking technique” using cone-beam CT in hybrid operating rooms^[12] and the use of mixed dye solutions for improved localization^[14]. The synthesis aimed to provide a balanced overview of each technique’s strengths and limitations, contextualized within the broader clinical landscape of pulmonary nodule management^[15].

Limitations: As a narrative review, this study is subject to certain limitations. The lack of a systematic review protocol introduces potential for selection bias. Additionally, the reliance on published literature may not capture the most recent developments or unpublished data. We aimed to mitigate these limitations through integrated searching and critical analysis of the included studies. Furthermore, the rapid evolution of localization techniques, particularly in robotic and hybrid operating room settings, means that some very recent innovations may not be fully represented in the published literature.

Results

Table 1 summarizes key studies for each major technique identified, providing an overview of their efficacy and safety profiles.

Table 1.

Key studies on localization techniques for small pulmonary nodules

Technique	Author, year	Study design	Sample size	Key findings
Hook-wire	Xu et al, 2021	Retrospective	161 patients	97.6% successful placement; 1.9% reported pain
	Zhang et al, 2022	Comparative	74 patients	Higher complication risk compared to medical glue
Anchored Needle	Li et al, 2022	Retrospective	93 patients with 107 nodules	99.1% successful localization; 0% dislodgement rate; lower pain scores (VAS 3.1)
	Zhou et al, 2024	Comparative	191 patients	Superior to hook-wire: no dislodgement, less pain, comparable complication rates
Microcoil	Park et al, 2017	Meta-analysis	46 studies	97-98% success rate; lower complication rates than hook-wire
	Mayo et al, 2009	Prospective	69 patients	97% success rate; 3% required chest tube for pneumothorax
Dye Localization (Methylene Blue)	Stephenson et al, 2015	Retrospective	30 patients	100% success rate; no complications
	Chu et al, 2022	Comparative	219 patients	Shorter hospitalization and fewer complications than hook-wire
Dye Localization (Indocyanine Green)	Anayama et al, 2015	Prospective	18 patients	100% successful localization; no adverse events
Lipiodol	Mogi et al, 2015	Retrospective	56 patients	98.2% successful VATS resection; 37.5% asymptomatic pneumothorax
	Lee et al, 2022	Prospective	57 patients	High success rate with indigo carmine and lipiodol mixture
Medical Adhesive	Yao et al, 2019	Prospective	74 patients	100% success rate; low complication rates
	Zhang et al, 2022	Comparative	84 patients	Lower complication rates compared to hook-wire
Ultrasound-guided	Khereba et al, 2012	Prospective	65 patients	93% successful localization
Electromagnetic Navigation Bronchoscopy	Marino et al, 2019	Prospective	93 patients	97.2% successful localization
Hybrid OR Approach	Chao et al, 2018	Prospective randomized	65 patients	Comparable efficacy to conventional CT-guided; improved workflow
	Yu et al, 2022	Prospective	27 patients	100% success rate with new intraoperative technique
Robotic-Assisted	Beqari et al, 2024	Comparative	90 patients	Improved accuracy with “sandwich marking technique”

Preoperative CT-guided techniques

1. Hook-wire Localization: Hook-wire localization remains one of the most widely adopted techniques globally. Studies consistently report high technical success rates, ranging from 94% to 98%. A large retrospective study by Xu et al^[16] involving 161 patients with 168 nodules reported a 97.6% successful placement rate. However, this technique is associated with notable complications. Kleedehn et al^[17] reported 7 wire dislodgements in their study of 52 patients, highlighting a key limitation of this method. The most common complication is pneumothorax, with incidence rates varying from 35% to 45% across studies. Pulmonary hemorrhage occurs in approximately 16% of cases. Wire dislodgement, a unique complication of this technique, is reported in 2-4% of cases and can lead to localization failure. A recent comparative study by Zhang et al^[6] found that hook-wire localization was associated with a higher risk of complications compared to medical glue localization.

2. Anchored needle localization: Anchored needle localization provides superior fixation through its unique four-claw anchoring mechanism. In a multicenter study of 215 patients with 247 nodules, anchored needle localization achieved a high technical success rate of 99.1%^[18]. Comparative studies have shown anchored needle reduces dislodgement rates compared to hook-wire (0% vs 4.8%, p = 0.029) while maintaining comparable safety profiles regarding pneumothorax (16.1% vs 21.4%) and pulmonary hemorrhage (23.7% vs 29.6%)^[19]. Patient comfort is improved with anchored needle, as evidenced by lower Visual Analog Scale pain scores (3.1 ± 0.4 vs 4.5 ± 0.6, p = 0.001), attributed to its use of soft sutures instead of metal wires^[19]. However, the relatively higher cost of anchored needle systems remains a potential limitation for widespread adoption^[20].

3. Microcoil Localization: Microcoil localization has gained popularity as an alternative to hook-wire placement. A meta-analysis by Park et al^[21] found comparable success rates to hook-wire (97-98%) but with a more favorable complication profile. Pneumothorax rates were lower at approximately 16%, and pulmonary hemorrhage occurred in about 6% of cases. Mayo et al^[22] reported a 97% success rate in their prospective study of 69 patients, with only 3% requiring chest tube placement for pneumothorax.

4. Dye Localization: Various dyes have been employed for nodule localization, each with unique properties:

1. Methylene Blue: While simple and cost-effective, its rapid diffusion limits utility. Stephenson et al^[23] reported a 100% success rate in their retrospective study of 30 patients, with no complications. However, Lin et al^[24] found a slightly lower success rate of 98.5% in their larger prospective study of 130 patients, but still with lower complication rates compared to hook-wire techniques. A recent comparative study by Chu et al^[15] found that methylene blue localization was associated with shorter hospitalization time and fewer complications compared to hook-wire localization.

2. Indocyanine Green (ICG): Offers the advantage of near-infrared fluorescence imaging. A study by Anayama et al^[25] reported 100% successful localization in 18 patients using ICG, with no adverse events. Recent studies have explored combined dye localization techniques to overcome limitations of single dye methods^[26].

Patent Blue: Demonstrates slower diffusion compared to methylene blue, potentially offering improved visibility in anthracotic lungs.

• (e) Lipiodol Localization: Lipiodol, an iodinated contrast medium, has shown high success rates in several studies. Mogi et al^[27] reported a 98.2% successful VATS resection rate in their retrospective study of 56 patients. However, they also noted a 37.5% rate of asymptomatic pneumothorax, highlighting the need for careful patient selection and monitoring. Lee et al^[14] introduced a novel technique using a mixture of indigo carmine and lipiodol for bronchoscopic navigation, which showed promising results in terms of localization accuracy and reduced complications.

• (f) Medical Adhesive Localization: This relatively new technique has shown promise in recent studies. Yao et al^[28] reported a 100% success rate in their prospective study of 74 patients, with low complication rates. The stable marking and flexible timing for surgery are notable advantages. Zhang et al^[6] further confirmed the efficacy and safety of medical glue localization in comparison to hook-wire techniques.

Intraoperative techniques

1. Ultrasound-guided Localization: Intraoperative ultrasound offers real-time, radiation-free localization. Khereba et al^[29] reported successful localization in 93% of cases in their prospective series of 65 patients. However, its efficacy is limited for deep nodules and in patients with emphysematous lungs.

2. Near-infrared Imaging: This technique typically uses ICG for fluorescence imaging. While promising, larger studies are needed to establish its efficacy and limitations.

Combined techniques

1. Electromagnetic Navigation Bronchoscopy (ENB): ENB allows for bronchoscopic dye marking or fiducial placement. Marino et al^[30] reported successful nodule localization in 97.2% of 93 patients using ENB-guided dye marking. The minimally invasive nature and avoidance of transthoracic complications are key advantages, but the high cost of equipment is a limitation.

2. Hybrid Operating Room Approaches: These approaches combine intraoperative imaging with minimally invasive surgery. Chao et al^[31] compared conventional CT-guided localization with intraoperative CT-guided localization in a hybrid OR in a prospective randomized study of 65 patients. They found comparable efficacy but improved workflow and reduced time between localization and resection in the hybrid approach. Yu et al^[13] introduced a new intraoperative technique using cone-beam CT in a hybrid operating room, demonstrating high success rates and low complication rates.

3. Robotic-Assisted Localization: Beqari et al^[12] reported on a novel “sandwich marking technique” using robotic-assisted CT-guided localization, which showed improved accuracy and reduced complications compared to traditional methods.

Comparative analysis of localization techniques

A comparison of six pulmonary nodule localization techniques was conducted through a radar chart visualization (Fig 1), integrating multiple clinical studies with our clinical practice experience. The analysis evaluated six key parameters on a scale of 1-10, with the following scoring criteria:

• Technical success: Based on reported success rates in localizing target nodules.

• Safety profile: Reflects the incidence and severity of reported complications.

• Procedural complexity: Considers technical demands, required expertise, and learning curve.

• Patient tolerability: Evaluates reported pain scores and patient satisfaction.

• Cost considerations: Encompasses equipment, disposables, and resource utilization.

• Workflow integration: Assesses compatibility with existing surgical workflows.

Figure 1.

Radar chart comparing six pulmonary nodule localization techniques across six key parameters as a reference for clinical decision-making.

Several limitations of this visualization approach warrant consideration. First, certain parameters, such as patient tolerability, partially rely on subjective assessments from clinical reports. Second, institutional factors and operator experience may influence actual outcomes, potentially limiting the generalizability of these comparisons. Third, the relative importance of each parameter may vary based on specific clinical scenarios and institutional protocols. Therefore, this visualization should serve as a general reference rather than an absolute measure of technique superiority.

Discussion

This integrated review of localization techniques for small pulmonary nodules reveals a dynamic and evolving field, driven by the need for precise, minimally invasive approaches in thoracic surgery. The choice of technique often depends on institutional resources, surgeon preference, and specific nodule characteristics, The evolution from single-modality approaches to combined techniques reflects the field’s response to complex clinical needs, while the development of hybrid approaches represents an evolving frontier in this field.

While traditional methods (e.g. hook-wire localization) remain widely used due to their established protocols and familiarity^[16,21], newer techniques are showing promising advantages in terms of patient comfort and reduced complications. Anchored needle localization has emerged as a promising alternative, despite comparable pneumothorax and hemorrhage rates to hook-wire. The four-claw design of anchored needle significantly reduces the risk of dislodgement, while its soft suture component improves patient comfort^[19]. Microcoil localization offers another alternative, with comparable success rates to hook-wire but a more favorable complication profile. However, the higher cost of anchored needle systems (approximately 250 USD) and microcoil localization (approximately 362 USD) compared to hook-wire (approximately 55 USD) may influence its adoption in some healthcare settings^[20].

The emergence of dye-based techniques, including the use of methylene blue, ICG, and patent blue, represents an attempt to address some of the limitations of wire-based methods^[24,25]. These approaches offer the advantage of not leaving a foreign body in the lung parenchyma, potentially reducing patient discomfort and the risk of dislodgement. However, the variability in dye diffusion rates and visibility presents its own set of challenges. The development of novel dyes and delivery methods, such as the use of lipiodol or medical adhesives, demonstrates ongoing efforts to optimize these techniques. A recent study by Lee et al^[14] introduced a promising technique using a mixture of indigo carmine and lipiodol for bronchoscopic navigation, which showed high success rates and low complication rates.

In addition to dye marking techniques, electromagnetic navigation bronchoscopy (ENB) is another promising minimally invasive approach for pulmonary nodule localization. Marino et al^[30] demonstrated successful nodule localization in 97.2% of patients using ENB-guided dye marking. However, the specialized equipment required for ENB, including electromagnetic tracking systems and dedicated software, contributes to higher procedural costs compared to traditional CT-guided techniques^[30]. Furthermore, the diagnostic yield of ENB may be influenced by nodule size and location, with lower yields reported for smaller and more peripherally located nodules^[32].

Hybrid operating room approaches, which integrate intraoperative imaging with minimally invasive surgery, offer several potential benefits in pulmonary nodule localization. A prospective randomized study^[31]. compared conventional preoperative CT-guided localization with intraoperative CT-guided localization in a hybrid operating room. While both techniques demonstrated comparable efficacy, the hybrid approach showed improved workflow efficiency and reduced time between localization and resection. The integration of intraoperative imaging allows for real-time confirmation of nodule location and resection margins, potentially reducing the risk of incomplete resection or the need for additional resections[31,32]. However, the availability of hybrid operating rooms and the additional training required for the surgical team may limit the widespread adoption of these techniques.

Robotic-assisted localization represents an emerging frontier in pulmonary nodule localization^[12], which demonstrated improved accuracy and reduced complications compared to traditional methods. The use of robotic systems allows for precise needle placement and may reduce operator radiation exposure. However, the high cost of robotic systems and the need for specialized training may limit their accessibility in many institutions.

Detailed Explanation of the Decision-Making Algorithm

Given the variety of localization techniques available and their respective advantages and limitations, selecting the most appropriate method for a given clinical scenario can be challenging. To address this, we propose a decision-making algorithm (Fig 2) that synthesizes the findings of this review and provides a structured approach for clinicians. Here, we elaborate on each step of the decision-making process:

1. Assessment of Nodule Characteristics: The first step involves evaluating the nodule’s size, location, and density. These factors influence the choice of localization technique. For instance, nodules ≤10 mm may require more precise localization methods, while those >20 mm from the pleura might benefit from techniques that can reach deeper into the lung parenchyma.

2. Evaluation of Patient Factors: Patient-specific considerations, such as pulmonary function, comorbidities, and history of allergic reactions, play a crucial role in technique selection. For example, patients with poor pulmonary function may be at higher risk for pneumothorax, favoring less invasive approaches like electromagnetic navigation bronchoscopy (ENB)^[30].

3. Consideration of Institutional Resources: The availability of imaging modalities and expertise in specific techniques varies across institutions. This step ensures that the selected technique is feasible within the given healthcare setting.

4. Technique Selection: Based on the above factors, the algorithm guides the clinician towards the most suitable technique:

• For solid nodules ≤20 mm from the pleura, CT-guided techniques like hook-wire, anchored needle, microcoil, or dye marking are often preferred due to their high accuracy^{[16,19,21,33]}.

• Deeper nodules or ground-glass opacities may benefit from lipiodol marking or medical adhesive techniques, which offer longer-lasting visibility^[27,28].

• Intraoperative techniques like ultrasound or near-infrared imaging are suggested when real-time localization is preferred, particularly for nodules visible on ultrasound in non-emphysematous lungs^[29].

• ENB is recommended when a minimally invasive approach is crucial, especially for patients at high risk of pneumothorax^[20].

• Hybrid OR approaches are suggested when available, offering the advantage of intraoperative CT-guided localization^[13,31].

• Robotic-assisted techniques should be considered when available, as they may offer improved precision and reduced complications^[12].

  • 5.Reassessment and Adjustment: The algorithm emphasizes the importance of flexibility. Clinicians should be prepared to combine techniques or modify their approach based on unexpected findings or complications during the procedure.

Figure 2.

Decision-making algorithm for small pulmonary nodule localization technique selection.

This algorithm serves as a general guide and should be used in conjunction with clinical judgment. It is designed to be adaptable to various clinical scenarios and institutional capabilities, promoting a personalized approach to nodule localization. As new techniques emerge and existing ones evolve, this algorithm may require periodic updates to reflect the latest evidence and best practices in the field.

Looking to the future, several trends are likely to shape the evolution of nodule localization techniques:

1. Integration of advanced imaging technologies: The incorporation of artificial intelligence and machine learning algorithms may enhance the precision of localization techniques and assist in real-time decision-making during procedures^[34].

2. Development of novel markers and contrast agents: Research into biocompatible, long-lasting markers that offer improved visibility across multiple imaging modalities could address some of the current limitations in dye-based techniques^[35].

3. Refinement of minimally invasive approaches: Continued improvements in bronchoscopic and transthoracic techniques may further reduce complication rates and patient discomfort^[36].

4. Standardization and comparative studies: As the field matures, there is a growing need for large-scale, comparative studies to establish best practices and develop evidence-based guidelines for technique selection^[37].

Conclusion

In conclusion, the field of small pulmonary nodule localization continues to evolve rapidly, with new techniques and refinements of existing methods offering improved accuracy and reduced complications. The choice of localization technique should be tailored to the specific characteristics of the nodule, patient factors, and institutional resources. As we move forward, the integration of advanced technologies and the development of standardized protocols will likely further enhance our ability to precisely localize and resect small pulmonary nodules, ultimately improving patient outcomes in thoracic surgery.

Ethical approval

This narrative review did not involve direct human or animal subjects. Nevertheless, the study protocol was submitted to the Institutional Review Board, and an exemption was obtained. The authors conducted this review in accordance with ethical standards for scientific research, ensuring accurate representation of the literature and proper citation of all sources.

Consent

Not applicable.

Sources of funding

This work was supported by the Chongqing medical scientific research project (Joint project of Chongqing Health Commission and Science and Technology Bureau) (grant number 2025MSXM166).All other disclosure statements in the manuscript are correct as presented.

Author’s contributions

H.Z. and C.G. conceived and designed the study. H.Z. and C.G. share corresponding authorship. C.Z. and L.L. conducted the comprehensive literature search and synthesized the information. J.Q. and G.Y. contributed to the analysis of current techniques and their clinical applications. Y.L. reviewed the historical context and emerging trends in pulmonary nodule localization. H.Z. and C.G. provided expert clinical insights and interpretation of the data. J.Q. created the figures and tables, including the novel decision-making algorithm. H.Z. and C.Z. drafted the initial manuscript. All authors critically revised the manuscript for important intellectual content. C.G. supervised the project and provided administrative support. All authors contributed to the discussion of future research directions. All authors had full access to all the information in the review and take responsibility for the integrity and accuracy of the review. All authors reviewed and approved the final version of the manuscript and had final responsibility for the decision to submit for publication.

Conflicts of interest disclosure

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Hao Zhang.

Provenance and peer review

Not commissioned, externally peer-reviewed

Data availability statement

The data and materials used in this narrative review are derived from previously published studies and are publicly available through the respective journal publications and databases. No new data were generated or analyzed in this study.